Introduction

Although traumatic injury of the brachial or radial artery is frequent, post-traumatic false aneurysm of the radial artery is a rare complication. False aneurysm formation often presents as a late complication of arterial injury. We present a case of false aneurysm of the distal radial artery concomitantly with complete cut-off of the brachial artery, median and ulnar nerves.

Case Report

A 17 year-old-man admitted with a little soft mass at the right wrist and an history of trauma to his right arm. The cause of the sharp injury was a broken glass three weeks ago. The accident resulted in a large injury which involved muscles, artery and nerves in the upper part of the right arm developed. In a local city hospital, the first intervention has been performed by a general surgeon and cut ends of the brachial artery were ligated. The patient had already been referred to a vascular surgery center.

Because of lack of health insurance, he had declined to go to another hospital. Three weeks later, the patient came to our institute with a swelling of the right wrist. A large incision scar at the mid-medial arm, multiple small scars throughout the right arm due to lacerations and a soft, non-pulsatile mass which has eroded the skin partially at distal region of the forearm as just over the radial artery was observed in the physical examination. Mildly ischemic right hand, pulslessnes of the brachial, radial and ulnar arteries were also detected. There was a partial sensory-motor deficit of the right arm and electromyographic evaluation revealed that the median and ulnar nerves had no sensory-motor action potential.

For preparation of the brachial artery reconstruction, a digital subtraction angiogram was performed to the patient. A 2 cm false aneurysm of distal radial artery and the occlusion of the mid-portion of the brachial artery was as a consequence of direct surgical ligature of the cut ends observed on the angiogram.

Figure 1

Figure 1 : Digital subtraction angiogram showing false aneurysm of the radial artery.

Figure 2

Figure 2: Digital subtraction angiogram showing the occlusion of the mid-portion of the brachial artery as a consequence of direct surgical ligature of the cut ends and collateral arteries.

Distal brachial, radial and ulnar arteries were visualized by collateral circulation. A 4 cm, end-to-end, reversed arm vein interposition graft was performed between proximal and distal ends of the brachial artery. Also, the false aneurysm in the radial artery was excised and end-to-end anastomosis was performed. One week later, we referred the patient to the neurosurgery department for repair of the nerves injuries, with palpable radial and ulnar arteries and negative Allen's test.

Discussion

Traumatic injury of peripheral arteries frequent occurs nowadays and aneurismal formation of traumatic arteries is not rare. A false aneurysm is usually called as a pulsating haematoma that communicates with an artery through a disruption in the arterial wall (₁,₂). Many false aneurysms of the radial artery were reported recently and most often localized in an area of arterial puncture or cannulation (₃,₄,₅). False aneurysms usually develop at perforated, weakened or injured arteries that contain pulsatile blood flow pattern and normal arterial tension (¹,²).

However, atherosclerosis or infection may play a role at the etiologic of the false aneurysm (²,³,⁴,⁵,₆). We presumed that the radial artery at the wrist on the ipsilateral side was punctured by an additional splinter of glass at the time of the original injury. In the most of the cases reported in the literature, false aneurysmatic arteries contained normal structure and blood pressure. We could not find any case with a false aneurysm under low blood pressure in the literature.

Cut ends of the brachial artery have been ligated in this case due to traumatic complete cut-off. There was non-pulsatile blood flow in the radial and ulnar arteries and pressure index was 40/110 mmHg. In other words, although there is no pulsatile flow there is still endotension. It should suggest that the development an aneurysm at low tension is indeed unusual and each false aneurysm is not a pulsating haematoma. Following vein graft interposition to the brachial artery, the pulsation was appeared over the false aneurysm and distal radial artery. Primary repair of the brachial artery was not considered because of the trauma was older more than 3 weeks. There was thrombosis in the cut ends and possibility of the endothelial damage. Graft interposition without crossing the elbow was performed with an arm vein graft. We presumed that the arm veins nearby which are perfectly satisfactory in a young individual.

Correspondence to

Dr Suat CANBAZ, Department of Cardiovascular Surgery, Trakya University, Medical Faculty, TR 22030 Edirne, Turkey Phone: 90 284 235 76 56 Fax: 90 284 235 06 65 E-mail: scanbaz@trakya.edu.tr